Acute liver failure associated with Garcinia cambogia use.

Millions of Americans regularly use herbal supplements, but many are unaware of the potential hidden dangers. Numerous supplements have been associated with hepatotoxicity and, indeed dietary/herbal supplements represent an increasingly common source of acute liver injury. We report a case of acute liver failure requiring liver transplantation associated with the use of Garcinia cambogia, a supplement widely promoted for weight loss. When patients present with acute hepatitis or liver failure from an unknown etiology, a careful history of supplement use should be performed.

Phenotypic identification and classification of functional defecatory disorders using high-resolution anorectal manometry.

BACKGROUND & AIMS: Disordered defecation is attributed to pelvic floor dyssynergia. However, clinical observations indicate a spectrum of anorectal dysfunctions. The extent to which these disorders are distinct or overlap is unclear; anorectal manometry might be used in diagnosis, but healthy persons also can have abnormal rectoanal pressure gradients during simulated evacuation. We aimed to characterize phenotypic variation in constipated patients through high-resolution anorectal manometry. METHODS: We evaluated anorectal pressures, measured with high-resolution anorectal manometry, and rectal balloon expulsion time in 62 healthy women and 295 women with chronic constipation. Phenotypes were characterized by principal components analysis of high-resolution anorectal manometry. RESULTS: Two healthy persons and 71 patients had prolonged (>180 s) rectal balloon expulsion time. A principal components logistic model discriminated healthy people from patients with prolonged balloon expulsion time with 75% sensitivity and a specificity of 75%. Four phenotypes discriminated healthy people from patients with abnormal balloon expulsion times; 2 phenotypes discriminated healthy people from those with constipation but normal balloon expulsion time. Phenotypes were characterized based on high anal pressure at rest and during evacuation (high anal), low rectal pressure alone (low rectal) or low rectal pressure with impaired anal relaxation during evacuation (hybrid), and a short anal high-pressure zone. Symptoms were not useful for predicting which patients had prolonged balloon expulsion times. CONCLUSIONS: Principal components analysis of rectoanal pressures identified 3 phenotypes (high anal, low rectal, and hybrid) that can discriminate among patients with normal and abnormal balloon expulsion time. These phenotypes might be useful to classify patients and increase our understanding of the pathogenesis of defecatory disorders.

Normal values for high-resolution anorectal manometry in healthy women: effects of age and significance of rectoanal gradient.

OBJECTIVES: High-resolution manometry (HRM) is used to measure anal pressures in clinical practice but normal values have not been available. Although rectal evacuation is assessed by the rectoanal gradient during simulated evacuation, there is substantial overlap between healthy people and defecatory disorders, and the effects of age are unknown. We evaluated the effects of age on anorectal pressures and rectal balloon expulsion in healthy women. METHODS: Anorectal pressures (HRM), rectal sensation, and balloon expulsion time (BET) were evaluated in 62 asymptomatic women ranging in age from 21 to 80 years (median age 44 years) without risk factors for anorectal trauma. In total, 30 women were aged <50 years. RESULTS: Age is associated with lower (r=-0.47, P<0.01) anal resting (63 (5) (≥50 years), 88 (3) (<50 years), mean (s.e.m.)) but not squeeze pressures; higher rectal pressure and rectoanal gradient during simulated evacuation (r=0.3, P<0.05); and a shorter (r=-0.4, P<0.01) rectal BET (17 (9) s (≥50 years) vs. 31 (10) s (<50 years)). Only 5 women had a prolonged (>60 s) rectal BET but 52 had higher anal than rectal pressures (i.e., negative gradient) during simulated evacuation. The gradient was more negative in younger (-41 (6) mm Hg) than older (-12 (6) mm Hg) women and negatively (r=-0.51, P<0.0001) correlated with rectal BET but only explained 16% of the variation in rectal BET. CONCLUSIONS: These observations provide normal values for anorectal pressures by HRM. Increasing age is associated with lower anal resting pressure, a more positive rectoanal gradient during simulated evacuation, and a shorter BET in asymptomatic women. Although the rectoanal gradient is negatively correlated with rectal BET, this gradient is negative even in a majority of asymptomatic women, undermining the utility of a negative gradient for diagnosing defecatory disorders by HRM.

The mechanics of left ventricular dysfunction in patients with Churg-Strauss syndrome.

BACKGROUND: Heart is frequently involved in Churg-Strauss syndrome (CSS). However, the mechanics of left ventricular (LV) dysfunction in CSS has not been studied. OBJECTIVE: To assess the mechanics of LV function and to characterize the contribution of longitudinal, circumferential and rotational deformation to LV dysfunction in CSS. METHODS: We enrolled 22 CSS patients (eight males, mean age 43.2 ± 9.5 years) in remission of their disease and 22 sex- and age-matched healthy subjects. All patients underwent conventional and two-dimensional speckle-tracking echocardiography. Global longitudinal, circumferential and rotational deformation parameters were calculated. RESULTS: CSS subjects demonstrated lower LV ejection fraction (EF) than controls (56.6 ± 15.0% vs 63.8 ± 3.4%; P < 0.05). When compared to those with LVEF ≥ 50% (n = 14), CSS patients with LVEF < 50% (n = 7) had decreased global peak-systolic longitudinal and circumferential strain/strain rate (all P < 0.001) and tended to have lower global peak-systolic radial strain (P = 0.05). There were no differences between these two subgroups in global peak-systolic radial strain rate and LV twist/torsion. When comparing individual systolic and diastolic parameters early diastolic longitudinal and circumferential strain rate demonstrated the highest correlation with corresponding global longitudinal and circumferential peak-systolic strain/strain rate (r < -0.80, P < 0.001 for all correlations). CONCLUSIONS: In CSS LV systolic dysfunction strongly correlates with longitudinal and circumferential, but not radial or rotational systolic components, indicating that impaired LV systolic function may result predominantly from impaired contraction of inner and middle, but not outer myocardial fiber layers. The spatial correspondence between systolic and diastolic deformation parameters suggests the similar impact of pathologic process on systolic and diastolic function in CSS.

Patients With Severe Gastrointestinal Dysmotility Disorders Receiving Home Parenteral Nutrition Have Similar Survival As Those With Short-Bowel Syndrome: A Prospective Cohort Study.

INTRODUCTION: Severe gastrointestinal dysmotility disorder (GID) constitute approximately 20% of patients requiring home parenteral nutrition (HPN), whereas short-bowel syndrome (SBS) remains the most frequent indication for HPN. This study's aim was to characterize GID patients and compare clinical parameters and survival to SBS patients. Similarly, clinical comparisons between sclerodermaand nonscleroderma patients were made. METHODS: Demographic and clinical data for all patients was extracted from the Canadian HPN Registry from January 1, 2003, to November 1, 2018. Kaplan-Meier method was used to estimate the unadjusted survival probability, and log-rank test was used to compare the survival probability between groups. RESULT: 270 patients (52 GID and 218 SBS) were included in the analysis. For all patients, higher mortality was associated with age (hazard ratio [HR], 1.02 [1.00-1.04]; P = .05), PN dependence (HR, 1.01 [1.00-1.02]; P = .04), hospitalizations (HR, 1.21 [1.10-1.33]; P < .001), and use of immunosuppressant (HR, 1.97 [1.02-3.82]; P = .04). The 5- and 10-year actuarial survival probabilities between GID and SBS were not significantly different (5-year: 70.0% vs 59.2%; 10-year: 79.6% vs 66.2% [P = .5], respectively). There was no difference in survival between scleroderma and nonscleroderma patients (P = .67). CONCLUSION: T5- and 10- year survival probabilities were similar between GID and SBS patients. The diagnosis of scleroderma had no effect on survival. Use of immunosuppressant, older age, PN dependence, and number of hospitalizations per PN duration are risk factors for mortality in both the GID and SBS groups.

Survival of Patients With Short-Bowel Syndrome on Home Parenteral Nutrition: A Prospective Cohort Study.

BACKGROUND: Survival of patients with short-bowel syndrome (SBS) receiving home parenteral nutrition (HPN) and associated factors have not been reported recently in North America. The objective of this study was to determine the long-term survival of adult patients with SBS as the primary indication for HPN and assess factors that may affect survival by using the Canadian HPN Registry. METHODS: This is a retrospective analysis of prospectively collected data extracted from the HPN registry, prior to approval of teduglutide in Canada. Using only incident cases, survival probabilities were estimated by using the Kaplan-Meier method for both full-cohort and nonmalignant SBS. Log-rank test was also used to test the differences in survival distributions between subgroups in the univariate analysis. To identify potential variables that are affecting survival distribution of patients for the multivariable analysis, Least Absolute Shrinkage and Selection Operator and stepwise selection procedure were used. RESULTS: There were 321 patients with a known duration receiving HPN (total, 2287 years), of whom 218 were entered into the registry within 1 year of initiation of HPN. Of 218 incident cases, 22 had active malignancy, along with SBS, and their survival time was significantly lower than those with nonmalignant SBS (P-value < .0001). The 5-year survival of nonmalignant-SBS patients was 81.9%. In this subgroup, there was no significant association between patients' survival and known intestinal anatomy, age, or sex. CONCLUSION: Patients with nonmalignant SBS who receive HPN have a 5-year survival of >80%. Known intestinal anatomical factors did not affect survival.

Non-Antibiotic Antimicrobial Catheter Lock Solutions in Patients on Home Parenteral Nutrition.

Patients on home parenteral nutrition (HPN) are dependent on central venous access for long-term sustenance, and catheter-related bloodstream infections (CRBSIs) are a major cause of morbidity and mortality in this patient population. As such, there is much interest in finding new methods for preventing CRBSIs in patients on HPN. As it is thought that these infections are preceded by microbial colonization of the catheter, one approach is to use antimicrobial catheter lock solutions. Although antibiotic catheter lock solutions have been present for decades, their use has been mostly limited to the treatment of CRBSIs due to concern for promoting microbial resistance. Recently, however, with the advent of non-antibiotic antimicrobial catheter lock solutions, this approach is gaining popularity as a promising method to decrease rates of CRBSI in HPN patients.

Extent of RV dysfunction and myocardial infarction assessed by CMR are independent outcome predictors early after STEMI treated with primary angioplasty.

OBJECTIVES: The aim of this study was to assess the prognostic value of right ventricular (RV) involvement diagnosed by cardiac magnetic resonance (CMR) early after ST-elevation myocardial infarction (STEMI). BACKGROUND: CMR allows accurate and reproducible RV assessment. However, there is a paucity of data regarding the prognostic value of RV involvement detected by CMR early after STEMI. METHODS: Ninety-nine patients (77 men, mean age 57 ± 11 years) who underwent CMR 3 to 5 days after STEMI treated with primary angioplasty were followed for 1,150 ± 337 days for cardiac events (cardiac death, nonfatal myocardial infarction [MI], and hospitalizations due to decompensated heart failure). Cox proportional hazards model was applied in stepwise forward fashion to identify outcome predictors. Event-free survival was estimated by Kaplan-Meier method and compared between groups by the log-rank test. RESULTS: Cardiac events occurred in 34 patients (7 cardiac deaths, 8 MIs, 26 hospitalizations). By multivariable analysis, the independent outcome predictors were left ventricular (LV) MI transmurality index (hazard ratio: 1.03 per 1%; 95% confidence interval: 1.01 to 1.04; p = 0.001), RV ejection fraction (RVEF) (hazard ratio: 1.46 per 10% decrease; 95% confidence interval: 1.05 to 2.02; p = 0.03), and RVMI extent (hazard ratio: 1.50 per each infarcted RV segment; 95% confidence interval: 1.11 to 2.01; p = 0.007). Compared with clinical data (global chi-square = 5.2), LV ejection fraction [LVEF] (global chi-square = 11.1), RVEF (global chi-square = 17.1), LVMI transmural extent (global chi-square = 26.0), and RVMI extent (global chi-square = 34.9) improved outcome prediction in sequential Cox model analysis (p < 0.05 for all steps). RVEF stratified risk in patients with LVEF <40% in whom the 4-year event-free survival was 66.7% for RVEF ≥40% and 40.0% for RVEF <40% (p < 0.05). CONCLUSIONS: The extent of RVMI and RV dysfunction assessed early after STEMI are independent outcome predictors, which provide incremental prognostic value to clinical data, LV systolic function, and infarct burden. Measurement of RVEF may be particularly useful to stratify risk in patients with depressed LV function after STEMI.